=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154723583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLY BETH BRYNER MSN, PRN,FNP-BD,CLC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2014
-----------------------------------------------------
Last Update Date | 09/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2091 BOX BUTTE AVE SUITE 500
-----------------------------------------------------
City | ALLIANCE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69301-4452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-762-2534
-----------------------------------------------------
Fax | 308-762-2764
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 873 COUNTY ROAD 66
-----------------------------------------------------
City | HEMINGFORD
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69348-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-762-2534
-----------------------------------------------------
Fax | 308-762-2764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 111738
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------